EFTA00313699 DataSet-9

EFTA00313699.pdf

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VISIT SUMMARY

            Life Steps OblGyn Healthcare For Women.                                          Date
            LLP                                                                           May 23, 2017

                                                                        Account ID
                                                                        Chan ID:

                                                                        Coverage         Insurance    Policy ID

                                                         SERVICES
Date Claim-Line Provider    X Ref   CPT      Units Mod    Description         Charges                   Adjusts Balance

                                                                              Patient Balance :                    505.00

                                                          RECEIPT
                                                                                                     Thank You I     U.

                                                         NEXT VISIT
on                   Time                 Duration       Pro.**               Location

                                                                                                        EFTA00313699

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26137f73ed8d48662768739d35444d5d7923ca8bbeed3804b99856ba72cc2861

Bates Number

EFTA00313699

Dataset

DataSet-9

Type

document

Pages

1

EFTA00313699.pdf

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